Vol. 118 No.

6 December 2014

Clinical importance of incidental ndings reported on

small-volume dental cone beam computed tomography
scans focused on impacted maxillary canine teeth
gramacI, BDS, MSc, MFDS, MOrth,a Giampiero Rossi-Fedele, DDS, MClinDent, PhD,b and
Esma J. Do
Fraser McDonald, BDS, MSc, PhD, MOrtha
Kings College London Dental Institute, London, UK, and The University of Adelaide, South Australia, Australia

Objective. To investigate the clinical importance of incidental findings reported for small-volume cone beam computed
tomography (CBCT) scans of impacted maxillary canine teeth.
Study Design. Radiology reports of CBCT examinations performed as part of diagnosis and treatment planning for impacted or
ectopically erupting maxillary canine teeth for 183 consecutive patients were assessed retrospectively. The scans were
obtained with a small-volume unit (3 D Accuitomo 80) with a field of view that was either 40
40 or 60
60 mm. The
findings were graded according to their clinical importance as low, intermediate, or high.
Results. Three hundred and forty incidental findings were reported. One of the incidental findings was of high importance
(0.3%), 97 were of intermediate importance (28.5%), and 242 were of low importance or anatomic variant (71.1%).
Conclusions. Incidental findings reported on small-dimension CBCT scans of impacted maxillary canine teeth rarely require
immediate attention; nonetheless, 28.8% would require follow-up. (Oral Surg Oral Med Oral Pathol Oral Radiol 2014;118:
e205-e209)

Systematic reviews have been performed on the clinical
use of cone beam computed tomography (CBCT) in
dentistry.1,2 CBCT use has generally been justied
when 2-dimensional radiography has not been able to
provide the necessary information required in the
management and treatment planning and when the in-
formation gained from CBCT examination would aid
this. Justication for CBCT includes the assessment of
impacted teeth and related resorption of adjacent teeth.2
Clinicians performing CBCT examinations should be
able to interpret normal radiologic anatomy and path-
ologic conditions of the teeth, jaws, and maxillary antra,
as well as the commonly encountered artifacts.2
Radiologic reports for dentoalveolar CBCT images
should include the entire image data set and be made by
oral and maxillofacial (OMF) radiologists or, in cases
for which this is impracticable, by adequately trained
general dental practitioners.2
An incidental nding has been dened as unantici-
pated information discovered in the course of testing or
medical care.3 In radiology this is described as an
occult entity discovered unexpectedly on an imaging
examination performed for an unrelated reason.4 There
is a plethora of studies on incidental ndings. Some
contain descriptions of developmental variants, and
a
Department of Orthodontics, Kings College London Dental Insti-
tute, London, UK.
b
School of Dentistry, The University of Adelaide, South Australia,
Australia.
Received for publication Jun 2, 2014; returned for revision Aug 23,
2014; accepted for publication Sep 5, 2014.
2014 Elsevier Inc. All rights reserved.
2212-4403/$ - see front matter
http://dx.doi.org/10.1016/j.oooo.2014.09.006
even jewelry has been reported as an incidental nding,
the presence of which is inconsequential and requires
no treatment or further investigation. Malignancies,
however, are one type of nding that requires further
follow-up or immediate intervention.4,5 The clinical
importance of incidental ndings for CBCT in OMF
radiology has been investigated using scans of large
dimensions that have focused on different areas of the
jaws.6-8 Distinction between clinically important and
unimportant ndings reduces unnecessary referral, im-
aging, and clinical procedures that may entail eco-
nomic, psychological, and physical consequences.4
The aim of this retrospective study was to evaluate
the nature and frequency of incidental ndings reported
in patients referred for small-volume CBCT performed
on impacted maxillary canine teeth and to categorize
the clinical importance of the incidental ndings.
MATERIALS AND METHODS
Radiographic examination
The radiographic examinations were performed with a
small-volume CBCT unit (3 D Accuitomo 80, J. Morita
Statement of Clinical Relevance
Cone beam computed tomography (CBCT) in-
vestigations have reported large numbers of inci-
dental ndings; however, their clinical signicance
needs better appreciation. This retrospective small-
volume CBCT investigation discusses the clinical
relevance of incidental ndings reported on scans
focused on impacted maxillary canine teeth.

e205
ORAL AND MAXILLOFACIAL RADIOLOGY
e206 DogramacI, Rossi-Fedele and McDonald
Manufacturing Company, Kyoto, Japan) for which
exposure parameters were a tube voltage of 70-90 kV
(based on subject size), a tube current of 3.0-4.0 mA,
and a scanning time of 17.5 seconds. The eld of view
(FOV) was either 40
40 mm or 60
60 mm
(diameter and height) depending on the size of the re-
gion of interest.
Radiologic reports
This retrospective study identied radiologic reports of
patients who were referred for radiographic examina-
tion as part of diagnosis and treatment planning for
impacted or ectopically erupting maxillary canine teeth.
Between February 2008 and December 2011, the
radiographic procedures were performed with the pre-
viously mentioned small-volume CBCT unit in the
Department of Dental Radiology, Kings College
London Dental Institute, Guys and St Thomas NHS
Foundation Trust, London, United Kingdom (UK). This
study was reviewed and approved by Guys & St
Thomas Hospitals NHS Foundation Trust Research &
Development ofces.
Incidental findings
The clinical quality of the CBCT images were rated as
being excellent (no fault) or acceptable (some faults but
not affecting image interpretation).9 Radiology consul-
tants who are registered specialists in dental and
maxillofacial radiology in the UK had reported on the
scan data sets, and these reports were assessed retro-
spectively to determine the nature and frequencies of
reported incidental ndings.
The incidental ndings were classied into the
following general categories:
(a) Anatomic variant or low-grade importance nding
(b) Intermediate-grade importance nding (follow-up
required)
(c) High-grade importance nding (requiring immediate
attention)
RESULTS
One hundred and eighty-three patients (129 female
patients and 54 male patients with mean ages of 18.1
and 18.4 years, respectively) were identied as having
undergone small-volume CBCT scans of impacted
maxillary canine teeth. One hundred and fty-two
(83%) of these patients (103 female patients and 49
male patients with an age range of 9-60 years) had 340
incidental ndings; some patients had multiple nd-
ings. There were 40 different types of incidental
ndings. The nature and frequencies of the incidental
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December 2014
ndings reported for these patients are presented in
Table I.
The only incidental nding reported as high-grade
importance was a keratocystic odontogenic tumor
(Figure 1). Twenty-seven types of incidental ndings
were classied as intermediate grade and 12 as
anatomic variants or low grade. Ninety-seven ndings
were considered intermediate grade (28.5%) and 242
low-grade or anatomic variant (71.1%).
DISCUSSION
CBCT scans capture substantially more details than 2-
dimensional radiographs, thus allowing for the detec-
tion of more reportable ndings. The frequency, type,
and clinical relevance of ndings depend on consider-
ations such as the area of focus and dimensions of the
eld of view (FOV). Dental, maxillary, and antral
incidental ndings are expected in small-volume scans
focused on upper impacted canine teeth, whereas
larger-dimension FOV scans exposed for other pur-
poses detect incidental ndings in the cervical verte-
brae, temporomandibular joint (TMJ), and salivary
gland regions.8,10-12 The patients age group, the loca-
tion of the potential nding (whether or not it is in the
primary area of interest), and the reporting clinician also
contribute to the detection and reporting of incidental
ndings.5,10,11,13,14 Intraoperator and interoperator
variability are well documented in the literature, and
what different radiologists consider as sufciently
important to include as incidental ndings, as well as
what constitutes an important nding, are subjective.5
In this investigation, the reporting of an enlarged fol-
licle associated with an impacted canine tooth could be
considered further information for diagnosis and treat-
ment planning rather than being considered an inci-
dental nding.
When using large FOV imaging focused on different
areas of the maxillofacial region, the frequency of
incidental ndings requiring immediate follow-up or
follow-up evaluation or appropriate referral has been
reported to be 37.6%, whereas the remainder required
continued monitoring.6 A retrospective CBCT
investigation reported that of 881 incidental ndings,
16.1% required denitive referral or intervention,
15.6% required monitoring, and the remaining 68.3%
required neither.7 In another investigation, 45.9% of the
individual incidental ndings were considered signi-
cant and required follow-up.8 With respect to the
maxillary sinus, 110 incidental ndings were identied
in 292 scans, and of these 38.1% required further
follow-up.9
The clinical importance of ndings varies depending
on their general category and location. For example, in
two investigations using large scan dimensions, the
airways presented with a high frequencies of incidental
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Volume 118, Number 6 gramacI, Rossi-Fedele and McDonald e207
Do

Table I. Nature and frequency of incidental ndings*

Clinical Total
Category Nature of incidental nding importance (a, b, c) number 340 Percentage
Airway area 115 33.8
Mucosal thickness a 60 17.6
Polyps b 5 1.4
Deviation of nasal septum a 18 5.2
Concha bullosa a 5 1.4
Bony spur on nasal septum a 15 4.4
Sinusitis/sinonasal disease/seasonal allergic rhinosinusitis b 10 2.9
Calcication in sinus wall b 1 0.3
Mucus retention pseudocyst b 1 0.3
Dental caries 13 3.8
Primary teeth b 6 1.7
Secondary teeth b 7 2
Dental anomalies 143 42
Pulp stones a 12 3.5
Enamel pearls a 1 0.3
Dilacerations, hooked/curved roots a 85 25
Talon cusp b 3 0.8
Dens invaginatus b 3 0.8
Pronounced cingulum/labial pit a 3 0.8
Altered/irregular morphology nonspecied a 36 10.5
Retained roots 6 1.7
Primary teeth b 5 1.4
Secondary teeth b 1 0.3
Endodontic 9 2.6
Radicular cyst b 4 1.1
Condensing osteitis b 1 0.3
Periapical radiolucency b 2 0.6
Internal root resorption b 1 0.3
Root fractures b 1 0.3
Periodontal 20 5.8
Widened periodontal ligament space b 7 2
Absent periodontal ligament space b 8 2.3
Bone loss b 5 1.4
Impacted teeth 3 0.8
Second permanent molars b 1 0.3
Third permanent molars b 1 0.3
Lower permanent canine b 1 0.3
Abnormalities in tooth number 12 3.5
Missing teeth b 1 0.3
Compound odontome b 7 2
Supernumerary teeth b 4 1.1
Cysts 12 3.5
Dentigerous cyst b 10 2.9
Keratocystic odontogenic tumor c 1 0.3
Lateral periodontal cyst b 1 0.3
Other ndings 7 2
Pronounced gubernacular tract a 3 0.8
Diminutive nasopalatine canal a 3 0.8
Displaced nasopalatine canal a 1 0.3
Findings associated with impacted 67 19.7
maxillary canine teeth
Enlarged follicle b 67 19.7
* The clinical importance of the ndings is identied by different letters: a low; b intermediate; c high.

ndings (34.9%-47.9%) though only 2.3%-6.2%
required follow-up/intervention or referral.6,7 End-
odontic lesions have represented a smaller percentage
overall (11.8%-11.3%); however, the vast majority
appear to be clinically signicant.6 Similar results were
obtained in our study: incidental ndings in the airway
area represented 33.8% of the total, and of those 4.9%
were classied as being of intermediate-grade impor-
tance. Endodontic ndings represented a smaller per-
centage (2.6%), though all required follow-up.
ORAL AND MAXILLOFACIAL RADIOLOGY
e208 DogramacI, Rossi-Fedele and McDonald
Fig. 1. Axial, sagittal, and coronal images that indicate part of a loculated radiolucent lesion superior to the apices of the upper
right central incisor and upper right lateral incisor teeth. The appearance of the lesion after viewing of the entire scan volume was
reported to be suggestive of a keratocystic odontogenic tumor.
From the otolaryngologists point of view, few of the
commonly reported ndings are of high clinical impor-
tance and other clinical elements should be taken into
account. Some ndings, such as bony erosion of a sinus
or nasal wall and fracture lines in trauma, need urgent
attention. Some ndings, such as certain retained roots,
dental caries, and apical pathosis, are usually diagnosed
and managed by the general dental practitioner (GDP)
before referral of the patient to a specialist for further
investigation or treatment. Such incidental ndings
detected in CBCT scans are likely to have been detected
in these patients because these patients are normally
under the care of a GDP. If the referring clinician in-
cludes a full clinical presentation and differential diag-
nosis to the CBCT radiographer and radiologist, this may
help delineate in the report those ndings that are
important incidentals from those that are apparent but
must nevertheless be reported on because they are
detected within the scan volume data set.
It was impossible to carry out a full direct com-
parison between the previously mentioned publications
and report on the clinical importance and signicance
of incidental ndings in OMF radiology.6-8 This is
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December 2014
because of the high variability and differences in the
categories used to classify ndings and because of the
obvious difculties in reaching a nal diagnosis based
solely on CBCT. For instance, when considering
endodontic ndings, there are a number of in-
consistencies. One investigation distinguished between
apical periodontitis and apical radiolucency,6 though
apical radiolucencies of endodontic origin are nor-
mally considered apical periodontitis. Furthermore,
retained root tips were considered to be endodontic.
Other instances of classication variation include the
allocation of sclerosing osteitis to the mandible or
maxilla group and periapical areas to the dental cate-
gory.8 It should be noted that sclerosing osteitis is a
radiographic variation of apical periodontitis related to
the overproduction of periradicular bone. One study
divided incidental endodontic ndings into 3 sub-
categories: (1) periapical rarefying osteitis, (2) peri-
apical rarefying and sclerosing osteitis, and (3)
periapical sclerosing osteitis.7 This suggests the need
for guidance for radiologists and other clinicians
regarding data gathering, management, and follow-up
action.4
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Volume 118, Number 6
CONCLUSIONS
Incidental ndings reported in small-volume CBCT
scans focused on impacted maxillary canine teeth
required immediate action in a small minority of cases
(0.3%). Furthermore, 28.5% required follow-up, and
the remainder were classied as either low-grade or
anatomic variant.
We would like to thank Soran Chawishly, Associate Specialist
Otolaryngology and Head and Neck Surgery, Royal Free,
Barnet & Edgware Hospitals, London, UK, for his input into
the classication of incidental ndings related to the airways.
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Reprint requests:
Miss Esma J. DogramacI
Department of Orthodontics
Kings College London
Floor 22 - Tower Wing
St. Thomas Street
London SE19RT
UK
esma.dogramaci@kcl.ac.uk